Call for new coroners' powers to stop repeat of Shipman

Coroners should be given a wide new power to investigate unusual patterns of death in the community so that villainous doctors can be caught at an early stage of their criminal behaviour, ministers are to be told this week.

Further powers would allow coroners and families greater access to medical records and new rights of entry where documents were being withheld.

A 300-page report calling for sweeping changes to the ancient office of the coroner is to be sent to David Blunkett, the Home Secretary, this week. Its principal findings match those of a separate public inquiry, chaired by Dame Janet Smith, into the murders committed by Harold Shipman. Michael Gallagher, the secretary to the coroners' service review team, which presented its findings to the Shipman inquiry in January, said the coroners' powers needed to be "beefed up".

The case of Shipman, the Bristol heart scandal and the inquiry into the murder of four children by a former nurse, Beverly Allitt, showed that the law must be changed to allow coroners to investigate at an early stage, he said.

Under the current rules, coroners, experienced lawyers and doctors can only use their powers when a named case of a suspicious death is reported to them. The review team, appointed by the Home Secretary in the summer of 2001, recommends that coroners should be able to trigger an investigation when there is evidence of an "irregular pattern of death or dying".

The Home Office appointed team, headed by Tom Luce, a former head of social care policy at the Department of Health, believes that such powers would lead to the early identification of rogue doctors like Shipman.

Mr Gallagher said: "Suspicions may be not strong enough for a chief constable to investigate but they are not going away."

Coroners are also felt to interpret their role "too cautiously," he said. The current rules were designed to deal with suspicious death in the "days of highwaymen when a body was found in a field". Death in the 21st century was much more likely to occur in a nursing home or a hospital, he said.

A central recommendation was to "put the bereaved family at the heart of the death investigation process", allowing people greater access to medical records.

Bereaved families would be granted the right see a doctor's notes if they had been used to help establish the cause of death. If the doctor's notes did not correspond with what the family knew of the medical condition of their dead relative then those suspicions could be brought to the attention of the coroner.

Mr Gallagher said that was one of the issues in the Shipman inquiry, where families complained that the medical notes did not support the medical history of their relatives.

The review team also wants to reduce the number of public inquests that are used as forums simply to determine which natural disease caused a particular death.

The traditional coroner's verdicts would become a "narrative analytic" rather than a simple finding of "suicide" or "death by misadventure". For example, a finding of "unlawful killing" would become "death at the hands of another" and include identification, where possible, of who was responsible for the death.